Migraine with Visual Aura and Photosensitive Epileptic Seizures

Summary: A relationship between epilepsy and migraine has long been postulated, but the nature of this interaction is still debated. We observed this association in a 23-year old man with a history of migraine with visual aura who had seizures at age 15 years while watching television. Waking EEG was normal, but sleep recordings demonstrated posterior spike-waves during sleep. During intermittent photic stimulation (IPS), a photoparoxysmal response occurred, maximum in occipital areas. Brain magnetic resonance imaging scan was normal. Seizures did not recur after 4-year treatment with valproate. He is currently seizure-free, but continues to have rare migraine with visual aura. The role of spreading depression or of a putative dopaminergic failure in occipital cortex is discussed.     

Genetic Contribution of Catechol-O-methyltransferase Polymorphism in Patients with Migraine without Aura

Background

Recent genetic association studies have investigated the possible genetic role of the dopaminergic system in migraine. Catechol-O-methyltransferase (COMT) is an enzyme that plays a crucial role in the metabolism of dopamine and its genetic polymorphism is associated with three- to fourfold variation of enzymatic activity.

Objectives

The objective of this study was to elucidate the role of the COMT polymorphism in the genetic susceptibility to migraine and its phenotypic expression in patients with migraine without aura (MWOA).

Methods

Ninety-seven patients with MWOA and 94 healthy volunteers were included in the study. After amplifying COMT genes by the polymerase chain reaction, we assessed their genotype frequencies and allele distributions by based on restriction fragment length polymorphisms. We classified all MWOA patients into two groups according to their COMT genotype: with the L allele (N = 43), and without this allele (N = 54).

Results

The genotype frequency and allele distribution of the COMT polymorphism did not differ between MWOA patients and the control group. During migraine attacks, MWOA patients with the L allele showed a higher pain intensity of headache (P = 0.001) and a higher incidence of the accompanying nausea/vomiting (94% vs 75%; P = 0.026) compared with MWOA patients without the L allele.

Conclusions

Although the COMT polymorphism does not appear to be involved in predisposition to the development of MWOA, this genetic factor could be involved in the phenotypic expression of MWOA.     

Reduced Cerebellar Inhibition in Migraine with Aura: A TMS Study

Subtle clinical cerebellar alterations have been found in migraine. Moreover, abnormalities in visual and motor cortex excitability consistent with a lack of inhibitory efficiency have been described in migraine, and it is known that cerebellum exerts an inhibitory control on cerebral cortex. Here, we investigated if impairment of cerebellar activity on motor cortex, i.e. reduced inhibitory control, can be found in migraine. Ten migraineurs with aura and seven healthy controls underwent a transcranial magnetic stimulation (TMS) protocol to investigate the cerebellar inhibitory drive on motor cortex: a conditioning pulse on right cerebellar cortex was delivered 5, 7, 10, 15 ms before a test stimulus (TS) on contralateral motor cortex. The cerebellar conditioning stimulus inhibits the size of the motor-evoked potential (MEP) produced by the TS alone by approximately 30–50%. Amplitude of MEP to TS alone showed no significant difference between patients and controls. Cerebellar conditioning TMS showed a significant deficit of cerebellar inhibition in migraine patients as compared to controls at all interstimulus intervals (5–15 ms) tested. Cerebellar inhibition is reduced in migraineurs. This could account, at least in part, for the reduced inhibitory efficiency previously showed in cerebral cortex of these patients.     

Evaluation of Cerebellar and Cerebral Volume in Migraine with Aura: A Stereological Study

Migraine is associated with an increased risk of deep white matter lesions and subclinical posterior circulation infarcts. A significant association between deep white matter hyperintensities and cerebral atrophy is true for various neurological diseases; it was not specifically proven in migraine. The aim of this study was to evaluate the cerebellar and cerebral volume and volume ratios for cerebellum using the Cavalieri principle. We also aimed to examine whether migraine with aura causes cerebellar and cerebral atrophy. Twenty three right-handed patients with migraine with aura diagnosed by means of the International Headache Society criteria and 24 age-matched subjects whose only health problem was headache due to rhinosinusitis and tension type headache were included in the study. Measurements of the cerebellar and cerebral volumes as well as cerebellar/cerebral volume ratios were made using Cavalieri’s principle by utilizing the point-counting methods. There were no significant differences between the volumes of cerebrum, cerebellum, and the ratio of cerebellum to cerebrum for males (p = 0.05, p = 0.10, and p = 0.64, respectively) and for females (p = 0.18, p = 0.89, and p = 0.24, respectively). Our results suggest that patients with migraine with aura do not have a significant difference in cerebellar and cerebral volumes and cerebellar/cerebral volume ratios compared to the non-migraine group.     

偏头痛患者血浆TNF水平的变化及其意义

用敏感细胞杀伤试验、ＭＴＴ比色法检测了３７例无先兆偏头痛患者和３５例正常健康人血浆ＴＮＦ的水平，结果发现偏头痛组ＴＮＦ水平为４９．１２±２１．２７μ／ｍｌ，高于正常对照组的４．８７±２．０１μ／ｍｌ（Ｐ＜０．００１），发作期高于缓解期（Ｐ＜０．０５）。认为ＴＮＦ在偏头痛的发病中起重要作用。     

Extra-Axial Medulloblastoma in the Cerebellar Hemisphere

Extra-axial medulloblastoma is a rare phenomenon. We report a case in a 5-year-old boy who presented with nausea, vomiting, and gait disturbance. He was treated with total removal of the tumor. This is the first case of an extra-axially located medulloblastoma occurring in the cerebellar hemisphere posteriolateral to the cerebellopontine angle in Korea. Although the extra-axial occurrence of medulloblastoma is rare, it should be considered in the differential diagnosis of extra-axial lesions of the posterior fossa in children.     

Migraine with Visual aura and the Risk of Stroke- a Narrative Review

ObjectivesPatients with migraine with visual aura (MwvA) often present to eye care providers for evaluation. A thorough ophthalmological history and examination is needed to exclude ophthalmologic disorders. Additionally, it has been increasingly recognized that MwvA is associated with ischemic stroke (IS). The aim of this narrative review is to provide a comprehensive overview of the differential diagnosis of MwvA and its association with IS.Materials and methodsWe conducted a PubMed search using key words including “migraine aura”, “visual aura without headache”, “late onset migraine accompaniment”, “migraine and stroke”, “migraine and atrial fibrillation”, and “migraine and patent foramen ovale (PFO)”. We narratively summarized the main findings of the identified studies in sections including age of onset and frequency of migraine with aura, stroke subtypes, and the role of cardioembolism in the migraine-stroke association.Results and ConclusionFor women younger than 50 years, MwvA is associated with an increased risk of IS, and the risk further increases in patients who also smoke and use oral contraceptives. Age of onset of MwvA 50 years or greater is associated with IS that occurs in late life. Studies reported that increased frequency of aura is associated with an increased risk of IS in women. MwvA is associated with an increased risk of cardioembolic stroke and a higher incidence of atrial fibrillation compared to migraine without aura. Most studies that assessed the migraine-stroke association were based on patients with MwvA. The risks of stroke associated with other types of migraine aura or aura without headache, as well as such association in men require further investigation. More data is needed to determine the absolute risk of stroke when evaluating MwvA in situations including smoking and low dose estrogen use, new or late onset (>50 years) MwvA, to facilitate the development of practice guidelines for stroke prevention in specific clinical scenarios.     

Migraine with aura

Around 15% to one-third of migraineurs experience aura. Aura is a fully reversible focal neurological phenomenon involving visual, sensory, speech, and/or motor symptoms that develops gradually and usually precedes the headache phase. The pivotal role of cortical spreading depression (CSD) as a mechanism underlying aura has been widely supported by a large body of studies. The diagnosis is based on the International Headache Classification Disorders III edition criteria. Aura is characterized by gradual development, duration of each symptom no longer than one hour, a mix of positive and negative features, and complete reversibility. Visual aura is the most common type of aura, occurring in over 90% of patients. When aura symptoms are multiple, they usually follow one another in succession, beginning with visual, then sensory, then aphasic; but the reverse and other orders have been noted. The accepted duration for most aura symptoms is one hour, but motor symptoms, which are rare, are often longer lasting. When a patient experiences for the first time a possible aura phase it's sometimes difficult to know if there was gradual or brutal onset of the symptoms. If the patient has no visual aura symptoms or simultaneous neurological symptoms, or presents neurological symptoms corresponding to a cerebral vascular territory, emergency exploration of a possible transient ischemic attack is necessary. Long duration (greater than one hour) of what may or may not be an aura phase, late onset of aura, or a dramatic increase in aura attacks should also be explored. The relative risk of ischemic stroke is significantly increased in migraine with aura. Combined hormonal contraception with estrogens significantly increases the risk of stroke in women with migraine with aura. It is recommended to start non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin as soon as possible during the aura phase, not to treat the aura, but to avoid or to diminish the headache phase. In case of failure of NSAIDs or aspirin it is recommended to use a triptan when the headache begins. The prophylactic treatments for migraine with aura are those used in migraine without aura based on very few randomized clinical trials specifically dedicated to migraine with aura.     

Aura and post-ictal headache in epileptic patients treated with flunarizine

Flunarizine is effective for the prophylaxis of both migraine attacks and epileptic seizures. Of 77 patients treated with flunarizine for intractable epilepsy, 28 had an aura preceding their seizures. In 22 this disappeared on flunarizine administration. Of 14 subject to post-ictal headache, 13 reported relief of this symptom on flunarizine.     

Migraine with psychiatric co-morbidity

Investigation of migraine co-morbidity has confirmed a strong association between depression, anxiety disorders (particularly panic and phobia) and migraine. However, research into the possible mechanisms underlying these associations remains limited. The literature also indicates that migrainers are at reduced risk of suffering from anxiety, mood disorders and substance-related disorders compared with medication overuse headache sufferers. Patients suffering from medication overuse headache sometimes exhibit addictive behavior for acute migraine drugs. Finally, migrainers show increased non-specific neurotic suffering.